Smackover-Norphlet School District Dear Parent/Guardian: Our school is participating in a special provision under the National School Lunch Program, either the Community Eligibility Provision (CEP) or Provision 2 (P2). The CEP and P2 provisions are directed toward schools with a high percentage of economically disadvantaged students. Under CEP and P2 all students receive a breakfast/lunch at no charge for the entire school year. However, to determine eligibility to receive additional educational benefits for your child(ren) you will need to complete an Income Verification Form. Completion of this form is voluntary and will only be used for the purpose of determining eligibility for additional educational benefits. If you have questions regarding these additional benefits that may be available to your child(ren), please contact the school at (870) 725-3101 1. DO I NEED TO FILL OUT A FORM FOR EACH CHILD? No. Use one Income Verification Form for all students in your household. We cannot use a form that is incomplete, so be sure to fill out all required information. Return the completed form to: Smackover High School, #1 Buckaroo Lane, Smackover, AR 71762 2. MY CHILD(REN) ALREADY RECEIVE MEALS AT NO CHARGE AT Smackover High School. WHY SHOULD I COMPLETE THIS FORM AS WELL? Many state and federal programs use socioeconomic status (that is, household size and income information) to determine eligibility for their programs. In addition, the primary state funding calculation uses socioeconomic status. By completing this form your school is able to determine eligibility for additional programs for which your child(ren) may qualify for. Regardless, your child(ren) will still receive meals at no charge at Smackover High School. 3.
WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro -rated share of expenses), do not include them.
4.
WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
5. WE ARE IN THE MILITARY. DO WE INCLUDE OUR HOUSING ALLOWANCE AS INCOME? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 6. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HIS/HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is received in addition to his/her basic pay because of his/her deployment and it wasn’t received before s/he was deployed, combat pay is not counted as income. Contact your school for more information. If you have other questions or need help, call Smackover High School at (870) 725-3101. Sincerely, Cheryl Corley Counselor Smackover High School
Income Verificaiton Form Letter to Families Page 1 of 4
INSTRUCTIONS FOR APPLYING Part 1: All Household Members (a household member is any child or adult living with you): All households should complete this part. List the name of each household member, the name of the school each child attends, and the child’s grade. If the child is a foster child, check the box for foster child. If a household member has no income, check the box for no income. All household members, incl uding foster children, should be included here. If you need additional space, attach a separate piece of paper and include all requested information.. If anyone in your household receives benefits from Supplemental Nutrition Assistance Program ( SNAP) benefits, please follow these instructions. Part 2: List the case number for one household member (adult or child) who receives SNAP benefits. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. If your child is homeless, a migrant or a runaway, follow these instructions. Part 2: Skip this part. Part 3: Check the appropriate category Part 4: Skip this part. Part 5: Sign the form. If you have foster child(ren) only, follow these instructions. You do not need to fill out a separate form for each foster child in your household. (If there are both foster children and non -foster children in your household, follow the instructions below for All Other Households). If all children in the household are marked as foster children in Part 1: Part 2: Skip this part. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. ALL OTHER HOUSEHOLDS, including WIC households, households with non-foster children and households with both foster children and non-foster children, follow these instructions: Part 2: Skip this part. Part 3: Skip this part. Part 4: Follow these instructions to report total household income from this month or last month. Section 1–Name: List all household members who have income. Section 2 –Gross Income and How Often It Was Received: List the income for each household member. Check the box to tell us how often the person receives the income—weekly, every other week, twice a month, or monthly. o Earnings from work: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. Net income should only be reported for self-owned business, farm, or rental income. o Welfare, Child Support, Alimony: List the amount each person receives, and check the box to tell us how often. o Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits. List the amount each person receives, and check the box to tell us how often they receive it. o All Other Income: List Worker’s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income received weekly, every other week, twice a month, or monthly. Do not include income from SNAP, federal education benefits and foster payments received by your family from the placing agency. o If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. Part 5: An adult household member must sign the form. Please include your address and phone number in the event there is a question about your information.
Income Verification Form Instructions for Completing Page 2 of 4
INCOME VERIFICATION FORM Smackover High School is participating in special provision under the National School Lunch Program, either the Community Eligibility Provision (CEP) or Provision 2 (P2) . Under CEP and P2, all children in the school will receive a breakfast/lunch at no charge regardless of income or completion of this form. However, to determine eligibility for various additional state and federal education program benefits that your school or child(ren) may qualify for, please complete, sign and re turn this form to {school}. t PART 1. ALL HOUSEHOLD MEMBERS Names of all people living in your household (First, Middle Initial, Last)
School the child attends, or indicate “NA” if household member is not in school
Check if a foster child (legal responsibility of welfare agency or court) If all children listed below are foster children, skip to Part 5 to sign this form.
Grade Level
Check if NO income
PART 2. BENEFITS
PART 3. HOMELESS, MIGRANT, RUNAWAY STATUS
If any member of your household receives SNAP, provide the name and case number or identifier for the person who receives benefits and skip to part 5. If no one receives these benefits, go to Part 3.
If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box HOMELESS MIGRANT RUNAWAY
NAME: CASE NUMBER:
(Example) Jane Smith
$200
$150
$0
Monthly
Twice Monthly
Every 2 Weeks
Monthly
Twice Monthly
Every 2 Weeks
Weekly
Monthly
Twice Monthly
Every 2 Weeks
Weekly
1. NAME 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (List only household members with Earnings Welfare, Pensions, income) from work child retirement, Social before support, Security, SSI, VA deductions. alimony benefits
Weekly
PART 4. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the box for how often it is received. Record each income only once. If you provided a case number in Part 2, you do not need to provide income information.
All Other Income (indicate frequency, such as “weekly” “every 2 weeks“, “monthly”) $50
/ monthly
$
$
$
$
/
$
$
$
$
/
$
$
$
$
/
$
$
$
$
/
$
$
$
$
/
$
$
$
$
/
PART 5. SIGNATURE (ADULT HOUSEHOLD MEMBER MUST SIGN) An adult household member must sign the form. I certify (promise) that all information on this form is true and that all income is reported. I understand that the school may get state and federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my child(ren) may lose benefits. Sign here: Address: Phone Number:
Print name: City:
Date: State:
Zip Code:
Cell Phone Number: Income Verification Form Household and Income Data Page 3 of 4
Privacy Notice To determine appropriate funding for educational programs and benefits, the Arkansas Department of Education requires schools and districts to collect the information in this form. This information is considered part of an educational record of a study and is therfore protected by federal and state privacy laws. Any sharing of this data is strictly limited to comply with federal and/or state laws. Regardless, all students enrolled in a Community Eligibility Provision or a Provision 2 school will receive a meal at no charge.
Non Discrimination Statement: In accordance with Federal Law and U.S. Department of Education policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write U.S. Department of Education, Office for Civil Rights, The Wanamaker Building, 100 Penn Square East, Suite 515, Philadelphia, PA 19107-3323 or call (215) 656-8541 (Voice). Individuals who are hearing impaired or have speech disabilities may contact U.S. DOE through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). The U.S. Department of Education is an equal opportunity provider and employer.
HOUSEHOLD CHECKLIST Have you included all your children as household members? For each household member receiving income, is the frequency checkbox checked? Have you signed the form?
DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52; Every 2 Weeks x 26; Twice A Month x 24; Monthly x 12 Total Income:
Categorical Eligibility:
Per: Week Every 2 Weeks Twice A Month Month Year
Date Withdrawn:
Eligibility: Free
Household size:
Reduced
Paid
Reason: Determining Official’s Signature:
Date:
Income Verification Form Household and Income Data Page 4 of 4